| Objective: In this study,by improving the transthoracic 2D(2DE)and real-time 3D echocardiography(RT-3DE)of patients after permanent pacemaker implantation,the relative anatomy of the right ventricular implant lead and the tricuspid valve was studied Positional relationship,evaluate the feasibility of RT-3DE for exploring the mechanism of lead-induced tricuspid regurgitation(TR),and whether the different paths of lead implantation in the right ventricular apex and median septum affect lead-valve interaction,To investigate whether the risk factors for aggravating tricuspid regurgitation after pacemaker implantation play a major role in the mechanical effect of lead interference valve,but not the risk factors for aggravating functional tricuspid regurgitation.Method: This study selected 130 patients To our hospital pacemaker program control room for pacemaker program monitoring from December 2018 to December 2019 and had implanted permanent dual-chamber pacemakers in our heart center for the first time.Preoperative echocardiography imaging data and complete 2DE and 3DTTE full-volume images of the right ventricular(RV)and zoomed images of the tricuspid valve after implantation.Observe the anatomical relationship between the lead and the valve and the impact of different positions on valve activity are divided into interference groups and non-interference Group;The pacing positions of the right ventricular apex and mid-septum were determined by the combination of X-ray,echocardiogram and electrocardiogram.The severity of tricuspid regurgitation was evaluated by the semi-quantitative classification of the maximum area of the TR beam to the maximum right atrium area(TR / RA area ratio,%)and the vena contracta width(VCW).In the end,VCW shall prevail,and it will be finally divided into no or slight(level 0),mild(level 1),moderate(level 2),and severe(level 3);Kappa test for reader consistency of the relationship between the lead and the valve and the measured VCW value of the offline stored image;Aggravated group defines the degree of regurgitation after operation to a clinically significant level,that is,moderate or severe;Pearson correlation analysis was used to analyze the correlation degree between the vcw and the 2DE parameter;By comparing the differences in baseline and echocardiography parameters between the two groups,the screened univariate predictors were used as independent variables,and postoperative tricuspid regurgitation was used as the dependent variable for multivariate logistic regression analysis.Results: 1.A total of 142 patients were included,among which 12 patients failed to obtain qualified RT-3DE images of acoustic window,which were excluded in further analysis,so 130 patients were finally included in this study(RVAP,61,67%;RVMSP,69,53%);The success rate of 3DE imaging was 92%.2.According to the RT-3DE pacemaker lead and tricuspid relative anatomical location of the object of study is divided into pacemaker lead interference tricuspid valve group of 40 cases(31%)(A5 %,S15%,P11%),lead did not interfere with the tricuspid valve group,90 cases(69%)(M44 %,AS8 %,AP2%,PS15%),right ventricular pacing lead distance complete RT-3 DE imaging to evaluate the average time was 77.92±33.08 months,of which 10 cases of follow-up time is less than 12 months.There were 22(73%)patients with no or trivialTR,72(55%)patients with preoperative level 1 TR,and 36(28%)level II TR,Postoperative TR classification: 1 case of grade 0,72 cases of grade 1(55%),53 cases of grade 2(41%),and 4 cases of grade 3(3%).Postoperative TR changes: 77 cases(59%)were unchanged,46 cases(35%)were graded at least one grade,39 cases(30%)were grade 1 and 7 cases(5%)were grade 2 Clinically significant exacerbations occurred in 34 patients(26%).There were 12 cases of inconsistent results among observers,8 cases of septum vs.posterior septum junction,and 4 cases of posterior vs.posterior septum junction.The observation agreement rate was 90.8%,and the kappa value was 0.82.3.Comparison between the interference group and the non-interference group:(1)Baseline data: Compared with the non-interference group,the intervention group had longer lead implantation time,more leads were located in the right ventricular apex,and preoperative patients with atrial fibrillation accounted for The ratio is greater,and the proportion of anticoagulant users is also greater.The differences between the above indicators between the two groups are statistically significant,and the remaining indicators are not statistically significant.(2)echocardiography parameters: There was no statistically significant difference between the two groups in the preoperative 2DE data.The postoperative datas of the two groups were compared with the RA-L,RA-T,RVEDD,RVEDD,RVE-T,MR,TR,PASP of the interference group.Significantly increased,of which the postoperative reflux index VCW(0.55±0.12VS0.3±0.1,P <0.001)was statistically significant between the two groups(P <0.05),indicating that the interference group deteriorated more after surgery obvious.4.Comparison between aggravated and non-aggravated:(1)Baseline data: aggravated group lead implantation time were longer(89.08±28.71VS67.99±36.87,P = 0.001).Greater proportion of implanted apical group(64.7% VS40.6%,P = 0.016)higher percentage of VP(71.62±38.97VS50.53±44.57,P = 0.011)The proportion of lead interference valve group was larger(88.2% VS10.4%,P <0.001).(2)Comparison of 2DE datas : Compared with the preoperative echocardiography parameters of the two group,the aggravated groupRA-T(37.86±5.58VS35.88±4.04,P = 0.047),PASP(33.51±9.59VS30.5±4.36,P = 0.044),and the MR flow rate,and VCW values were all smaller than those without aggravated,and the differences were statistically significant,which may be related to the greater proportion of mild tricuspid regurgitation before.Comparing the postoperative parameters of the two groups,the datas of RA-L,RA-T,RVEDD,RVE-T,TR,PASP,and VCW with aggravated were higher than those non-aggravated and the difference between the groups was statistically significant,indicating that the right heart echocardiography parameters of aggravated group is worse than that non-aggravated.4.Correlation analysis found that TR regurgitation evaluation index VCW was highly correlated with RA-L,RA-T,RVEDT and its preoperative changes,TR,PASP,but not with LVEF.5.Select the univariate predictive factors affecting TR exacerbation and perform multivariate binary logistic stepwise regression analysis to find that lead interference valve is an independent risk factor for TR exacerbation after pacemaker implantation(OR 13.492,95% CI 3.822-47.627,P <0.01).Conclusion: Real-time 3D echocardiography can clearly show the lead path and its anatomical relationship with the tricuspid valve,and found that the success rate of transthoracic 3DE imaging can reach 92%,which is feasible in the study of the mechanism of induced of tricuspid regurgitation by the lead.Among them,In the interference group,the VCW was larger after implantation and the effect was more significant.The proportion of the lead located in the RVA in the interference group was 62.5%,which seemed to be more likely to collide with the valve.The accuracy and cause of the results Need further research.Pacemaker lead implantation can increase the incidence of TR aggravate and lead interference valve is an independent risk factor for TR aggravate after pacemaker operation,but the additional role of factors that cause functional TR exacerbation in this process cannot be ruled out.Regarding right ventricular pacing on left ventricular function,the interaction between TR and right ventricular function requires more prospective and long-term follow-up studies. |
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